Helping vulnerable populations
Outlining the framework that is helping vulnerable populations better access pain management services in New South Wales formed the premise of Jenni Johnson’s plenary ‘Pain Management: a wicked problem for vulnerable populations’. Melissa Mitchell reports.
The question is a complex one: How do you take the very specific knowledge you have about the needs of people experiencing complex chronic pain conditions and then apply it on a state-wide basis to improve access to care and to evidence-based treatment? For Jenni Johnson, who works for the Agency for Clinical Innovation (ACI) and pain clinics in New South Wales, it is a question that has driven a rethink on how pain management services are structured and delivered.
As the ACI’s stream manager (trauma, pain and rehabilitation), it has been Jenni’s responsibility to review access to pain management services and to identify those vulnerable populations who, for a variety of reasons, don’t attend hospitals where the services are available—namely those living in rural areas, those with disabilities, Aboriginal and Torres Strait Islander populations, people of culturally-diverse backgrounds and the aged.
Jenni set out to evaluate the special issues for consideration among vulnerable populations by engaging in broad consultation across geographic locations. Working with cultural consultants highlighted the need to move programs for pain management from the hospital environment into the community, as that is where they are best placed to achieve access, Jenni says.
‘The communities are experts in their own lives and we needed to take a step back consider ourselves students, and design solutions together,’ she says.
As the national invited speaker on the final day of the Australian Pain Society’s 39th annual scientific meeting on the Gold Coast, Jenni detailed the rethink on pain management and outlined how a pilot project, which started on the Central Coast of New South Wales in 2014, has now expanded to improve access to pain management services across the state. The first stage of the framework involved developing a pilot program, beginning with the writing of a manual that was co-designed with input from the very community it was endeavouring to reach, including the clinicians who would be delivering it.
Addressing those attending her plenary session, Jenni said: ‘We know that access to pain management clinics is difficult for mainstream populations, but we also know through our evaluation they are effective. But what about the vulnerable? We are not seeing these populations in representative numbers at our pain services, so I want to talk about how we are shifting our traditional consultative model to a population health model to address the needs of the vulnerable.’
She said pain management in New South Wales had undergone something of a revolution due to a confluence of factors: financial, administrative and policy support to actually bring about change. Central to this was a focus on not only improving the patient experience of care (including quality and satisfaction) but also on improving the outcomes of care provision while reducing the per capita cost of healthcare; so becoming more efficient while concurrently applying the change management approaches.
‘The question then was “how do we take the programs out of hospital and into community?” … so what we did is worked in different communities to build skills and capacity in clinicians working in primary care to run these programs out in community,’ Jenni says. ‘We wrote a number of facilitator manuals for physiotherapists and psychologists working in the private and primary care sector. In partnership with the University of Sydney, Pain Management Research Institute, we provided training through a webinar series addressing the principles of pain management, so the clinicians could learn how to run the program in their own practices, preferably as a physiotherapist–psychologist combination, because chronic pain is best managed with multidisciplinary input.
‘It needs a psychosocial approach, and a lot of physios struggle with the “psycho” aspect, so we optimally recommend that clinicians undertake the program in a partnership. These programs run over six weeks for three hours each week; around 10 participants come along as a group to learn from the physio and psychologist to understand what pain is and how to manage it.
‘They [patients] do activity-based interventions as well as relaxation and mindfulness, problem-solving, goal-setting—there are many elements to the pain program. What we’re trying to do is take the very specialist services that physios have, say in neurology or in hospitals, and make it accessible to physios who are working in community,’ Jenni says.
Training for physiotherapists and psychologists who are not pain specialists and who are working in regional and rural areas has been provided free by selected Primary Health Networks (PHN) interested in addressing the problem of pain in their community and supporting GPs to manage it from a non-pharmacological perspective. The webinar training provided runs over seven weeks, a commitment of about 90 minutes a week, on a weeknight.
Armed with the manual and the additional training, facilitators of the pilot program began their work on the Central Coast with 32 people with low- to-moderate complexity pain. The program was quickly taken up in other parts of rural and regional New South Wales including the north and south coasts, Broken Hill and in parts of metropolitan Sydney. Jenni says ACI has since been contacted from interested parties in South Australia, opening up potential for the program to run nation-wide.
‘In 2014 we took the pilot and the evaluation to other PHNs and said to them “These are the results, would you be interested in replicating this work locally?” At the same time opioid prescribing was becoming a big issue and GPs were saying, “I don’t know what else to do” [with pain patients].
So the perfect solution was to refer them to physios and to psychologists who have an understanding of pain and who had the tools to run a program supporting the biopsychosocial model.
‘To date, we run about 35 programs across New South Wales. That has been a really positive outcome and is making pain management programs more accessible,’ she says.
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